Progress on HRH: Accessibility

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Durgesh, a community health worker, gathers mothers and expectant mothers from their homes prior to addressing a meeting on malnutrition in Jahangir Puri, New Delhi, India
Credit: Prashanth Vishwanathan/Save the Children

The accessibility dimension of human resources for health (HRH) looks at whether there is equitable access to health workers. To achieve Universal Health Coverage (UHC), all people must be able to obtain the health services they need and this requires all people being able to access a health worker when and where they need one.

However, health workers are not evenly distributed within and between countries. The biggest health worker shortages are usually to be found in the poorest parts of the world but even high income countries have challenges to maintain a balanced distribution of health workers across the country.

In most countries, the majority of health workers tend to be located in capital cities and other wealthier, urban areas. Like all people, health workers prefer to settle in environments where there is access to better facilities, continuing education and better living standards for families.

Poor working conditions and inadequate pay, as well as the lure of better opportunities and living conditions in other parts of the country, outside of the public health sector, or abroad also deter health workers from working in the places of greatest need, or from staying in the public health sector altogether.

It is difficult to track whether the distribution of health workers has improved because of the lack of comparable data over time though analysis of a few countries for the GHWA report suggests workforce distribution is often inequitable.

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The spatial dimension of HRH is only one dimension of accessibility. There are also other barriers that prevent people accessing a health worker including the time and cost of transport to facilities; clinic open hours and staff attendance; whether infrastructure is accessible; whether referral mechanisms are working effectively; and the direct and indirect costs of services (both formal and informal).

Reducing financial barriers to access is a major priority within the UHC agenda since it is widely accepted that the direct costs of paying for healthcare both deter people from using services and also cause impoverishment. An increasing number of countries are moving away from funding health through direct, out of pocket payments and are developing progressive pooled funding mechanisms.

A new analysis of the impact of user fees removal on HRH notes that in some countries user fee removal may increase workloads beyond the capacity of current workforces. It is therefore important that plans to achieve UHC take into account projected increases in demand and the HRH requirements to meet them.

There are many policy tools available to distribute the health workforce more equitably. These range from providing financial incentives to health workers in remote postings, ensuring that continuing professional development and training is available beyond urban areas, prolonging the residency period during which workers have less choice over their posting, and providing non-financial incentives such as free housing, better facilities, security and free access to health care. A multi-faceted and flexible approach is needed for sustained improvement such as that proposed by WHO .